Suture guide and ruptured tissue repair

ABSTRACT

A suture guide may include a base, a tissue guard extending from the base, and two flanking posts affixed to the base on opposite sides of the tissue guard. The posts may extend from the base in parallel planes, and each of the posts may define a plurality of channels passing through its width. The channels may be so oriented that, for each post (a) the channels define suture needle guide paths in one or more planes, and (b) at least one channel is not perpendicular to a long axis of the first flanking post, so that it defines an oblique suture needle guide path. The tissue guard may be connected to the base by a connector so adjustable as to control spacing between the posts and the tissue guard.

CROSS-REFERENCE TO RELATED APPLICATIONS

This application is a division of U.S. application Ser. No. 11/738,775,filed Apr. 23, 2007, which is a continuation-in-part of PCT/US05/038490,filed Oct. 25, 2005, which claims the benefit of U.S. ProvisionalApplication No. 60/621,720, filed Oct. 25, 2004, both of whichapplications are hereby incorporated herein by reference. U.S.application Ser. No. 11/738,775 also claims the benefit of U.S.Provisional Application 60/745,673, filed Apr. 26, 2006, which is herebyincorporated herein by reference.

BACKGROUND

Tendon rupture is a debilitating event that limits motion and can causepain. Rupture can result from overexertion, trauma, and age-relateddegeneration, among other causes. Surgical repair of the ruptured tendonis typically required; tendinous tissue has poor wound-healingproperties, and the torn ends of the tendon separate from one other dueto contraction of the unrestrained muscle attached to one tendon end.

Surgical repair of a ruptured tendon is typically performed by puttingone or more sutures through each torn end and then sewing thecomplementing sutures to one another, thereby winching the torn endstogether and restoring the connected muscle to its normal restinglength. Two risks of tendon repair include inadequate strength of therepair and potential soft tissue problems from surgical exposure.Accordingly, it would be best if a tendon could be repaired through asmall incision but with a strong repair. With a small incision, theneedles used to advance the sutures through the tendon may be advancedmanually, without any guides, but this practice risks placing thesutures unevenly, so that the tendon's natural geometry and strength arenot restored, and the repair is weak. One approach, described in U.S.Pat. No. 6,200,327 to Assal, provides a two-piece guide member withaligned channels in each piece. The aligned channels allow a user toadvance a loaded needle horizontally through the tendon in a precise andrepeatable fashion. However, the structure of the Assal devicenecessarily limits each suture to just one pass through the tendon; thisresults in a potentially weak stitch that provides a minimum of surfacearea for the suture to engage the tendon.

SUMMARY

The present disclosure describes the structure and use of various sutureguides that facilitate the precise and reproducible placement ofmultiple passes of a suture through a tissue.

A suture guide may include a tissue guard and a flanking post disposedto one side of the tissue guard. The flanking post may define aplurality of channels passing through its width. The channels may be sooriented that they define suture needle guide paths in one or moreplanes that do not intersect the tissue guard.

A suture guide may include a tissue guard and a flanking post disposedto one side of the tissue guard. The flanking post may define aplurality of channels passing through its width. The channels may be sooriented that they define suture needle guide paths in one or moreplanes that do not intersect the tissue guard, and so that at least onechannel is not perpendicular to the long axis of the flanking post, sothat it defines an oblique suture needle guide path.

A suture guide may include a tissue guard and two flanking postsdisposed to opposite sides of the tissue guard. Each flanking post maydefine a plurality of channels passing through its width. The channelsmay be so oriented that they define suture needle guide paths in one ormore planes that do not intersect the tissue guard.

A suture guide may include a tissue guard and a flanking post disposedto one side of the tissue guard. The flanking post may define one ormore channels passing through its width. The channel may be so orientedthat it defines a suture needle guide path in a plane that does notintersect the tissue guard. The guide may include a second flanking postthat also defines one or more channels passing through its width. Thechannel of the second flanking post may be so oriented that it defines asuture needle guide path in a plane that does not intersect the tissueguard. The channel of the first flanking post and the channel of thesecond flanking post may define guide paths in the same plane.

A suture guide may include a tissue guard and a flanking post disposedto one side of the tissue guard. The flanking post may define aplurality of channels passing through its width. The channels may be sooriented that a) the channels define suture needle guide paths in one ormore planes that do not intersect the tissue guard; and b) at least onechannel is perpendicular to the long axis of the flanking post, so thatit defines a horizontal suture needle guide path. All channels definedby the flanking post may be perpendicular to the long axis of theflanking post.

A method of suturing a tissue may include positioning a suture guidedisclosed herein against a tissue to be sutured, so that the tissueguard overlies or supports the tissue and the flanking post flanks afirst side of the tissue. A first needle, with a first suture attached,may be advanced through a needle guide path in the post and then thetissue, so that ends of the first suture emerge from the first side anda second side of the tissue. A second needle, with a second sutureattached, may be advanced through a needle guide path in the post andthen the tissue, forming a needle track, so that ends of the secondsuture emerge from the first side and the second side of the tissue. Thesutures may be detached from their respective needles. The first suturemay be attached to the end of the second suture that is on the secondside of the tissue. The second suture may be retracted through theneedle track, thereby pulling the first suture through the needle trackand disposing its end on the first side of the tissue.

BRIEF DESCRIPTION OF THE DRAWINGS

FIGS. 1-5, 11-13, and 16 show perspective views of various exemplaryembodiments of suture guides.

FIGS. 6-8B show top plan views of exemplary embodiments of sutureguides.

FIGS. 9-10 and 14-15 show side elevation views of exemplary embodimentsof suture guides.

FIGS. 17-17A show perspective and elevation views, respectively, ofanother exemplary embodiment of a suture guide.

FIGS. 18-34 depict exemplary uses of an embodiment of a suture guide.

FIG. 35 is a photograph of an exemplary suture guide positioned on asubject for an Achilles tendon repair.

DETAILED DESCRIPTION

The suture guides disclosed herein provide suture needle guide pathsthat assist a surgeon or other user in positioning stitches in a preciseand reproducible way. In particular, the disclosed suture guides includeneedle guide paths that allow the user to create multiple passes of astitch through a tissue, which are stronger than a single pass.

FIG. 1 shows one exemplary embodiment of a suture guide 10. In thisembodiment, the suture guide includes a tissue guard 40 and a flankingpost 20. In the depicted embodiment, the tissue guard has a concaveshape, and the concavity faces toward the back of the device. This shapecan facilitate a snug contact between the guard and an underlying convextissue. The guard may various degrees of concavity, from, for example,about 120 degrees of arc to about 180 degrees of arc. The guard may alsohave other shapes, including a flat plate, rounded corners, squared-offcorners, v-shaped, and others. The free end of the guard (the tip) maybe curved, tapered, rounded, and/or thinned, akin to the blades of avaginal speculum, to facilitate sliding along tissue.

The flanking post is disposed to one side of the tissue guard. The postdefines a plurality of channels 50, 70, 80, etc. that extend through thepost's width, from external orifices 52, 72, 92, etc. to internalorifices 54, 74, 84, etc. The channels are positioned so that a needlepassing through one of the channels will move in a plane that does notintersect the tissue guard. This detail is shown more clearly in FIGS.6-10. When the device is positioned on a tissue, the needles will thenpass through the tissue behind (FIG. 4) or in front (FIG. 5) of theguard without being obstructed by the guard. “Behind” and “front” inthis sense refer to the guard as viewed in the figures. When a sutureguide is positioned for an Achilles tendon repair, for example, theneedles will pass anterior or posterior to the tissue guard, where“anterior” and “posterior” are defined with respect to the patient'sanatomy.

One or more of the channels may be parallel to the width of the flankingpost, i.e., parallel to an axis W through the width of the post, toensure that a needle passing through them will not intersect the tissueguard. However, one or more channels can be oriented non-parallel sothat sutures passing through the tissue are in different planes and donot interfere with one another. The non-parallel channel should be soangled that its axis does not intersect the tissue guard. FIG. 7 showsone exemplary embodiment having non-parallel channels 56, 58.

One or more of the channels, exemplified here as channel 50, may beperpendicular to the long axis L of the flanking post in addition tobeing parallel to the post's width. This channel can define a horizontalsuture needle guide path. (The path does not appear horizontal in thedrawing due to the perspective.) At least one other channel, such aschannel 70, is not perpendicular to the post's long axis, although it isstill parallel to the width. This channel defines an oblique sutureneedle guide path. Some of the oblique channels may run in a firstnon-perpendicular direction, such as channels 70 and 80, while otheroblique channel may run in a second non-perpendicular directiondifferent from the first direction, such as channels 90 and 100.Adjacent oblique channels running in different directions can share acommon orifice, such as orifice 84 shared by channels 80 and 90. Itshould be noted that the depicted post embodiment defines nine channels,but alternative embodiments may have more or fewer channels inaccordance with particular applications.

In this embodiment, the post and the tissue guard are connected to oneanother by a rod 42. The guard can be affixed to the connector, whilethe post can be clampable and repositionable. For example, the postcould be clamped in the illustrated position during part of a suturingprocedure, then moved to the other side of the rod during another partof the procedure. A sliding arrangement can also allow the post to bepositioned an appropriate distance from the tissue guard for a giventissue size or to accommodate the local anatomy.

FIG. 2 shows another embodiment of a suture guide similar to theembodiment of FIG. 1, except that instead of a connecting rod, the guidehas a shaft 44 to which the post is rotatably mounted by arm 46. Thepost can rotate about the shaft and thereby swing from one side of theguard to the other side. The post and/or shaft can include a mechanismto help ensure that the post is rotated into an appropriate position,i.e., one in which the tissue guard will not obstruct needles passingthrough the channels. Examples of appropriate mechanisms include apaired notch and detent, a stop, a clasp, a clamp, and alignmentmarkings on the post and/or shaft to guide the user. The tissue guardmay also be rotatable about the shaft, so that it can be swiveledbetween an anterior position and a posterior position.

FIG. 3 shows yet another embodiment of a suture guide which includes asecond flanking post 30 disposed to the side of the guard opposite fromthat of the first flanking post. The second flanking post, asillustrated, is a mirror image of the first post and includes aplurality of channels that complement the channels of the first post. Itis preferred that the channels are so aligned that a needle passingthrough a channel in the first post will glide smoothly into asimilarly-directed channel in the second post. An example of this isshown in FIGS. 20-21. In the embodiment depicted in FIG. 3, the postsare connected to the guard by a base 45. The base, guard, and post orposts can be of unitary construction. Alternatively, the parts could beconnected by an adjustable connector as described earlier, such as arod/clamp, or a bolt/screw arrangement, so that the posts may bepositioned on either side of the guard in the optimal positions for agiven use.

The disclosed suture guides can also be so positioned that the tissueguard supports tissue rather than covers it. This can be done by turningthe device over and slipping the guard behind the tissue to be sutured.The guard would help hold the tissue to be sutured away from surroundingtissue and would also protect tissue deep to the tissue to be sutured.

FIGS. 6-10 show additional views of various suture guide embodiments todepict certain features more clearly. FIG. 6 is a transverse crosssection of the FIG. 3 embodiment taken at the level of channel 50 andprojected upward. Width axis W and long axis L are depicted. Tissueguard 40 is positioned so that the suture needle guide paths aresituated in one or more planes behind the guard, so that needlesadvanced through those paths will enter tissue held behind the guardduring use. The guard does not extend so far back as to block the needlepath planes, as this would interfere with suturing. However, as shown inFIG. 8, the guard may extend backward just up to the foremost guideplane, so that the edge of the guard may further assist needle Nguidance. FIG. 8 also shows an alternative embodiment of guard 40, inwhich the edges of the guard define grooves 48 that may be used to slidesuture catches up and down the guard. This feature will be described inmore detail with reference to FIG. 19.

FIGS. 8A-B show alternative embodiments in which channels are replacedwith grooves formed on the post surfaces. In FIG. 8A, posts 20′ and 30′have less depth than in other embodiments and define grooves 51 and 53,respectively. Needle N slides in the grooves. The tissue guard is shownas coming up to the plane of the needle's passage, but this need not beso. FIG. 8B shows another embodiment of a suture guide have groovesinstead of channels in posts 20″ and 30″. In some embodiments, the postor posts do not define channels or grooves; instead, the post surfaceprovides a planar needle guide.

FIGS. 9-10 show side view of suture guides. FIG. 10, in particular,shows a suture guide with handle 110 to simplify the grip andpositioning of the device.

FIGS. 11-15 show alternative embodiments of suture guides that includeadditional protuberances on the guard. The guard depicted in FIG. 11includes catch receptacles 120 and 130. These protuberances preventsuture catches that are slid along the guard from advancing beyond theguard and potentially damaging tissue beyond the guard. In someembodiments, a guard may include a protuberance 140 disposed along theguard. A complementary guard on the other side of the guard is notvisible in this perspective view, but is better seen as protuberance 150in FIG. 15. The protuberances 140 and 150 help hold away body structuresthat are deeper than the tissue being sutured, to prevent the suturecatch from inadvertently contacting the deep structure, and also to keepthe deep structure away from the suture needle guide paths.

It is preferred that the mid-guard protuberances be so positioned thatthey do not cross the suture needle guide paths, so that they do notinterfere with use of the device. It is also preferred that themid-guard protuberances do not interfere with the movement of suturecatches along the tissue guard. In some cases, as shown in FIG. 12, theprotuberance 140′ can be shaped so that its body is clear of the guardand suture catch 180 (discussed in more detail with reference to FIG.19) can pass unimpeded. FIG. 13 shows detail of an alternate embodiment,in which the catch receptacles 120′ and 130′ are larger than theprevious embodiment. The receptacles should be blunt, not sharp, so thatthey do not poke surrounding tissue. FIGS. 14 and 15 show side views ofembodiments that include catch receptacles and/or mid-guardprotuberances. (Note that, as shown in FIGS. 14-15, the sides of thetissue guard need not extend into the space between the posts as they doin FIGS. 6-7.)

FIG. 16 shows another embodiment in which the guard 40′ is tapered alongits length. The guard may gradually narrow as it approaches the guidebase. This tapered shape may be preferred when the device is used tosuture a tendon or other tissue which itself has a tapered shape.

The suture guide can be formed from a variety of materials, includingmetals and plastics. A disposable, single-use device can be made fromplastic and have a unitary design, so that it could be made by injectionmolding. A sterilizable, reusable device can be made from metal, such asstainless steel or other metals typically used in surgical applications.

FIGS. 17-17A depict another embodiment of a suture guide, which includesa second tissue guard 41 pivotably coupled to the other tissue guard byhinges 42. The hinges may be lockable by, for example, a ratchet or ascrew (not shown). The tips of the blades may be adapted for slidingalong tissue, as disclosed above. The two guards permit simultaneousprotection of tissues above and below the tissue being sutured using thesuture guide. To position the double-guard device, the guards are swungto an open position, and the device is slid over the tissue like asleeve. The guards can then be swung against the tissue and tightened,if desired.

EXAMPLES

FIGS. 18-34 describe, step-by-step, exemplary uses of suture guides.These examples depict the use of a suture guide having two posts, butthe depicted uses can also be accomplished using a one-post sutureguide, in which the device is flipped over, or the post repositioned,when maneuvers involving the second post are called for. These figuresare schematic representations and are not necessarily depicted to scale;rather, they illustrate the principles of use. The end result of theexemplary uses is to have a suture threaded through the tissue in acrisscross pattern.

FIG. 18 shows the starting condition for an exemplary suturingprocedure. The suture guide is placed over a tissue T to be sutured sothat the guard covers the tissue and the flanking posts lie on eitherside of the tissue. (In another embodiment, a device could be turnedover, so that the tissue guard supports the tissue.) A first needle 160is advanced through the horizontal channel 50, emerges into the spacebetween the posts, and then enters the tissue. The horizontal channelpositions the needle for a horizontal trajectory through the tissue. Theneedle may have a sharp tip 162 to facilitate clean entry of the needleinto the tissue. As the needle passes through the tissue, it forms ahorizontal needle track. The needle 160 is loaded with a first suture170; the suture is drawn through the horizontal track. Once the needleemerges on the far side of the tissue, the first suture is accessible onthe second side of the tissue. (In alternate embodiments, the horizontalchannel might not be used or might be omitted from the device.)

Next, shown in FIG. 19, a suture catch 180 may be advanced up throughthe guard. The catch may be guided up the suture through a groove, suchas groove 48 (FIG. 8). The catch may have a hook 182 or similarstructure to catch a suture. The hook may be curved to various extents.The hooks shown are curved through about 180 degrees, but hooks may becurved less, such as about 120 degrees, or may be curved more, such asthrough about 270 degrees, about 300 degrees, about 330 degrees, about350 degrees, or about 360 degrees, so that the hook more resembles aneye or a loop. The hook is maneuvered to catch the suture (or may havebeen already placed in position before the passage of the first suturein FIG. 18), and then the catch is pulled down through the guard, takingthe first suture with it. The catch may then be advanced again upthrough the guard to be in position for the next suture.

In FIG. 20, a second needle 190 is advanced through one of the obliqueguide paths of the first post, into the tissue, out the far side of thetissue, and, optionally, into the corresponding channel in the secondpost. This motion forms an oblique track through the tissue. As shown inFIG. 21, a second suture 200 is attached to the back of the secondneedle. The second suture has a catch on its front end, such as a loop202, and the second suture may be attached to the second needle byanother loop 194 attached to the back of the needle. Once the front endof the second suture 200 emerges on the far side of the tissue, it isdetached from the second needle, hooked by the suture catch 180 (FIG.19), and brought down through the guard. The back end of the secondsuture protrudes from the first side of the tissue so that it can begrasped later. Next, shown in FIG. 22, the first suture 170 is threadedthrough the catch 202 on the second suture. In some embodiments, thecatch could be tightened like a noose to grasp the first suture.Alternatively, the first and second sutures could be knotted orotherwise bonded. The back end of the second suture is then pulled sothat the second suture is retracted back through the oblique track andpulls the first suture along with it. FIG. 23 shows the end of thisstep, with the first suture now making one horizontal pass through thetissue and one oblique pass. The distance between the exit point of thehorizontal pass and the entry point of the oblique pass may vary; it isexaggerated in the drawing to show detail. In practice, such as during arepair of the Achilles tendon, the separation between the exit and entrypoints may be in the range of about 4 millimeters (mm) to about 26 mm,about 4 mm to about 12 mm, or about 5 mm to about 10 mm. In someembodiments, the separation is about 5 mm. The separation can varydepending on factors such as the size or consistency of the tissue to besutured (for example, other tendons or other tissue types), the locationor extent of the rupture, or the particular anatomy of the subject. Theseparation distance can be controlled, for example, by providing severalsuture needle guide paths from among which the user can select, or byinstructing the user to reposition the suture guide.

FIG. 24 shows the next step. The second needle is reloaded with thesecond suture or another suture. Alternatively, a third needle, with itsown suture is provided. This needle 190′ is advanced in an obliquechannel from the other side of the tissue. If the suture guide has twoposts, this channel would be in the second post. If the guide has onepost, that post would be moved to the other side. This needle isadvanced all the way through the tissue (FIG. 25), thereby forming asecond oblique needle track, and brings its suture 200′ out to the firstside of the tissue. The suture 200′ is detached from the needle bycutting link 194′. A suture catch is advanced along the guard to hookthe suture and bring its catch 202′ down, and, as shown in FIG. 26, thefirst suture 170 is threaded through it, as before. The suture 200′ isthen backed out through the second oblique needle track, pulling thefirst suture 170 with it. FIG. 27 shows the state of the procedure atthis point: the first suture 170 has now made three passes through thetissue.

The process may be repeated one or more times to give the sutureadditional oblique passes through the tissue. FIG. 28 shows theconditional after one additional oblique pass is formed. The danglingend of the first suture 170 may be pulled into the space between thefirst post and the guard using a catch 180, and the entire procedurerepeated, so that both ends of the first suture are stitched through thetissue in a crisscross pattern. The end result of this procedure isshown in FIG. 29. Alternatively, or in addition, a second suture 210,shown in FIG. 30, can be introduced through a channel in the second post(or relocated single post) and stitched through the tissue in minorimage to the first suture 170. As many additional sutures as desired canbe placed in the tissue in this manner.

The entire process may then performed on the other end of the rupturedtissue, as shown in FIG. 31. In some embodiments, sutures could bepassed through the other ruptured tissue end using conventionaltechniques. The free ends of sutures placed in each tissue end arepulled together and tied, as shown in FIG. 32, thereby completing thetissue repair.

A suture used in ruptured tissue repair may include an obstructionaffixed to the suture. The obstruction may be so sized as to be unableto pass through needle and/or suture holes formed in the ruptured tissuewhen stitching the ruptured tissue as described herein. The obstructionmay thus help prevent the suture from being pulled through the tendon.The obstruction may have a disk shape, such as suture button 220 shownin FIG. 33, an elliptical shape, a spherical shape, an oblong shape, orother shapes. The obstruction may be threaded onto the suture, at anappropriate point during a tissue repair, in such a way as to preventthe suture from sliding through the obstruction. The obstruction mayhave a shape complementary to the tissue against which it will nestle,such as a concave surface against a rounded tissue.

The obstruction may be made of a wide variety of materials, such asmetals, biocompatible metals, polymers, biocompatible polymers,resorbable materials, biodegradable materials, and/or combinations ofthese. In the case of an obstruction made from a nonresorbable ornondegradable material having a disk, spherical, or other circular-typeshape, the diameter may be in the range of about 1 mm to about 10 mm,about 3 mm to about 10 mm, about 3 mm to about 6 mm, or about 4 mm toabout 6 mm. Other shapes may have a largest dimension in similar ranges.If the obstruction is made from a resorbable or degradable material, itssize may be larger.

FIGS. 33-34 depict an exemplary use of an obstruction during a tissuerepair. After a horizontal pass is made and the end of suture 170 ispulled through the tissue (the situation after that shown in FIG. 19 andbefore that shown in FIG. 20), the obstruction 220 may be threaded ontothe suture (FIG. 33). The obstruction may be positioned on the suture ata location that leaves enough suture on either side to complete thediagonal stitches. The suture may be pulled back through the tissue tobring the obstruction snugly against the tissue (FIG. 34). The repairmay then resume as shown in FIG. 20 et seq.

FIG. 35 is a photograph of an exemplary suture guide 10 in use for anAchilles tendon repair. The guide includes flanking posts 20, 30, tissueguard 40, and base 45. The guide is positioned superior to a subject'sheel H. The flanking posts rest outside the skin on either side of asmall incision that is made to reveal a portion of ruptured tendon T.The tissue guard in this exemplary use is slid in through the incisionto rest below the ruptured tendon and protect underlying tissue. Duringthe stitching process, a needle carrying a suture is advanced throughthe appropriate post, through the skin, through the tendon, then throughthe skin and the other post. After the suture is separated from theneedle, its free end is pulled back through the post and the skin usinga hook or similar structure described elsewhere in this disclosure.

Exemplary uses of the disclosed suture guides include Achilles tendonrepair, anterior tibial tendon repair, repair of extensor tendons,flexor tendons to the fingers, tendons of the arm as well as othertendons and other tissue types.

A kit may include a suture guide disclosed herein and one or moreneedles threaded with suture. A kit may include an obstruction foraffixing to a suture.

1. A suture guide, comprising: a base; a tissue guard extending from thebase; and two flanking posts affixed to the base on opposite sides ofthe tissue guard, the posts extending from the base in parallel planes,each of the posts defining a plurality of channels passing through itswidth, the channels so oriented that, for each post: a) the channelsdefine suture needle guide paths in one or more planes; and b) at leastone channel is not perpendicular to a long axis of the first flankingpost, so that it defines an oblique suture needle guide path; whereinthe tissue guard is connected to the base by a connector so adjustableas to control spacing between the posts and the tissue guard.
 2. Thesuture guide of claim 1, wherein the base and posts are of unitaryconstruction.
 3. The suture guide of claim 1, wherein the guard andposts are so coupled to a shaft as to make the guard rotatable withrespect to the posts.
 4. The suture guide of claim 1, wherein theconnector comprises a bolt/screw arrangement.
 5. The suture guide ofclaim 1, wherein the guard has a concave shape, and the concavity facesthe suture needle guide paths.
 6. The suture guide of claim 5, whereinthe edges of the guard concavity extend to, but not into, a forward-mostsuture needle guide plane.
 7. The suture guide of claim 1, wherein theguard has a cylindrical arc shape.
 8. The suture guide of claim 1,wherein the guard tapers along its length.
 9. The suture guide of claim1, wherein the guard has a rounded free end.
 10. The suture guide ofclaim 1, wherein the one or more planes in which the suture needle guidepaths are defined do not intersect the tissue guard.
 11. The sutureguide of claim 1, wherein a flanking post defines at least two channelsthat are not perpendicular to the long axis of that flanking post. 12.The suture guide of claim 11, wherein at least two channels notperpendicular to the long axis of that flanking post share a commonorifice.
 13. The suture guide of claim 1, wherein at least two channelsthat are not perpendicular to the long axis of a flanking post extendthrough that flanking post in directions different from one another. 14.The suture guide of claim 13, wherein the directions are parallel to thewidth of that flanking post.
 15. The suture guide of claim 1, wherein atleast one channel of a flanking post is perpendicular to the long axisof that flanking post so that it defines a horizontal suture needleguide path.
 16. The suture guide of claim 15, wherein that flanking postdefines at most one channel perpendicular to the long axis of thatflanking post.
 17. The suture guide of claim 1, wherein all channelsdefined by a flanking post are not perpendicular to the long axis ofthat flanking post.
 18. The suture guide of claim 1, wherein at leastone channel of a flanking post is parallel to the width of that flankingpost.
 19. The suture guide of claim 1, wherein the channels of aflanking post are parallel to the width of that flanking post.
 20. Thesuture guide of claim 1, wherein the at least one channel of a flankingpost is non-parallel to the width of that flanking post.